By

Dennis O. Balogu, Ph.D., M.P.A.

dbalogu7@yahoo.com

Introduction

Africa is the most affected continent with the AIDS virus.  The continent has a disproportionate share of 70% of the HIV cases.  Most of these cases were found in African countries south of the Sahara.  In countries such as Uganda and South Africa the number of infections is very high.  In South Africa, the rate of infection has increase from 1% to 20% in the last 12 years (UNAIDS, 1999).  The effect is that many of the children in the hardest hit areas are being raised by their grandparents because their parents have either died or become incapacitated by the AIDS disease.  This has disrupted family, community, and the lives of all affected.

Nigeria has an estimated infection rate of 3.0 percent to 5.8 percent of the African population. There is a great deal of concern by the government and the Nigerian people that if the spread is not controlled, there could be a catastrophe. Although the more recent information (Daily Trust, May 4, 2004) quoted Nigeria’s Minister of Health, Prof. Eyitayo Lambo as saying that the rate of the pandemic infection has dropped from 5.8 percent in 2001 to 5.0 percent in 2003.  Nigeria is a densely populated country of about 135 million people (UNAIDS, 1999).  Hence, the government is giving too much attention to the HIV virus.  So far, the federal government of Nigeria has given a total of 100 billion naira (about one billion U.S. dollars) toward fighting the pandemic.  In the same vein, many non governmental organizations have made substantial contributions. Also, state governments and communities are making large contributions in cash and kind.

Developing a Culture that Affects Health Care Management

African governments and bureaucracy originated from the colonial governments of the past. Colonial governments’ bureaucracies were peculiar to the colonies and were designed to exploit the colonized Africans. So these bureaucratic systems were inherited and practiced by the African independent countries without revising them. And the maintenance of pre-colonial administrative culture became part of post-independent Africa.  Because civil servants of the newly independent countries derived personal benefits from practicing this administrative system, they rigidly adhered to the system.  The system itself appears to mimic the “spoilt” era bureaucracy in the United States with its inefficiency, nepotism, and corrupt practices kept intact.

In the Nigerian system, bureaucratic corruption had been perfected through several years of successive military dictatorships.  Hence, the level of inefficiency and corruption in government reached unprecedented levels with the military government eras in Nigeria.  There is, in existence, a rigid hierarchical administrative system which allows public officials to practice nepotism and fraternization in the public domain.  Citizens have to give brides in exchange of government information which in the United States, or other developed countries, are freely obtained through the Freedom of Information Act.  In this system, public administrators may decide at any time to stop doing their work, take a vacation, go on strike with slightest provocation and resume duties whenever they want and without any penalty.  Friends, family members, “home boys” of public administrators are “hired first and fired last” in the public service. The result of this is apathy at work which is deepened by inability of the local, state, and federal governments to pay workers’ salaries on time.  Sometimes workers are owed up to six months worth of wages.  In response to this, workers have been known to frequently go on strike for several weeks.  This leads to the reduction in productivity and frustrates proper administration of public programs such as the ones serving the HIV/AIDS pandemic.

The federal government of Nigeria have budgeted several billion of naira to help HIV/AIDS patients obtain treatment and medicine.  Because the administration of government programs’ are not proactive in providing the needed services to the HIV/AIDS patients, many of the patients do not receive frequent treatment and medicine.

Civil Service Development (Bureaucratic System)

Nigeria is one of the African countries colonized by the Empire of Great Britain in the Nineteenth Century. It was first ruled by proxy of British Royal companies as protected territories known as the Southern (Niger) Protectorate and the Northern (Niger) Protectorate. These two were distinct in character and tradition. While the Northern Protectorate had been significantly Islamized, the Southern Protectorate was primarily uninfluenced by foreign doctrine and practiced primarily traditional African religion until it was Christianized. The two protectorates were amalgamated under one government by a British colonialist, Lord Lugard in 1914; hence called Nigeria (Niger Area) in reference to the famous River Niger.

The British established a strict top-to-bottom colonial Bureaucratic system whose mission was limited to the economic exploitation of the territory for the sole benefit of Great Britain. As such, the colonialists devised policies that will produce the desired results. So, there was (a) Direct Rule in Southern Nigeria in which the Europeans directly ruled the people with the most suppressive system, which is exploitation of natives; and (b) Indirect rule in Northern Nigeria where by the Colonial Governor ruled through religious leaders. The Colonialists did not care about the excessiveness of the surrogate leaders provided that the economic exploitation of the Colonialists was achieved. This set in motion a bureaucratic development at the top but fractured in implementation. While the managers and administrators did anything they wanted, the technicians had no authority to protest. This eventually led to apathy, redundancy, and inefficiency. Workers not being regularly paid resulted in corruption developing among the working class (Bolman and Deal, 2003). The current day public administration of Nigeria evolved from this bureaucratic frame. This culture of apathy redundancy, inefficiency, and corruption was further strengthened by a series of military dictatorships which ruled the country for more than 38 years (more than 68 percent of the time since Independence in 1960).

So civil service in Nigeria today appears to represent a clone of (1) the American Andrew Jackson’s Spoilt period when only political supporters were eligible for public service, and (2)The Classical Period when qualified people were employed in the civil service. Thusly, there is an entrenched corruption by the elite in civil service.

Efforts to reduce the spread of AIDS

Several National and International Non-governmental organizations (NGOs) have been making “cash and kind” contribution toward reducing the spread of the AIDS virus. Among them are the World Band and United Nation Development Programs (UNDP).

Organization Changes

The Nigeria Administrative departments have a lot of responsibility in restructuring and redesigning strategies for improving the government’s track record and the department that has direct responsibility for working with HIV patients and preventive services (Bolman and Dean, 2003, p. 8).  The Nigerian policy makers must develop enhanced policies guiding the prevention, treatment, social behavior, and acceptance of HIV patients by some communities which recognize HIV patients as taboos. Public department manager’s have the responsibility of carrying out the policies as well as ensuring that the overall health and productivity of the agency are improved (Bolman and Dean, 2003, p. 8).  The government of Nigeria should also make an allowance for hiring consultants to help the public managers in occasions where the managers’ expertise is not adequate in achieving complete success.  The re-engineering process being espoused should aim at establishing an organization that is (1) responsible to the needs of the clients, staff and community.  In order to accomplish a restructure, the Nigerian government administrators must overcome the dilemma of “holding to the old patterns (ways of doing business) which is ineffective” (Bolman and Deal, 2003, p. 34), and embrace the development of a new system of doing things.  The essence is to encourage Nigerian administrators to change the existing bureaucratic culture, and create a new way of thinking about how government services ought to be carried out (Wilson, 1989, p. 94).

Change the Culture

The new culture must aim at increasing the communities and clients’ trust and faith in Nigeria’s administration and bureaucracy.  Therefore, the culture should aspire to be uncorrupted, and be responsive to the needs and welfare of the citizens.  However, the administrators must realize that discipline would be the first casualty in an organization where the welfare of workers is ignored.  Obviously, not paying the salaries of workers in time may exacerbate such vices as official corruption, absenteeism, as well as frequent strikes and other “work-to-rule” options.

Empowerment of Government Administrative Managers

The Government’s staffs that work with the health care facilities should be retained and empowered by strengthening their expertise for handling HIV/AIDS cases.  The report by Jegede-Ekpe (2003), showed that in Nigeria, stigmatization of the HIV infections and misconceptions about how the virus proliferate are some of the factors hindering the treatment, training, and success of government programs.  Bureaucrats should be trained to respond to the three roles which Pfeffer and Salaneik (1978) said lead to successful management.  The roles are:

(1)The Responsive Roles—In this role, the bureaucrats must adjust the organization activities to face the challenges presented to the environment.  The AIDS pandemic is one of the most serious public health hazards that Nigeria ever faced.  The Nigerian health care administrators should be empowered, through policy changes or modification, to use their discretion to meet the demands of their clients and the community.  Administrators and their street-bureaucrats should work together in developing training programs in order to upgrade the services to their clients.  Because the AIDS pandemic is a new threat as well as a new challenge, the administrators should have the discretion of hiring non-governmental consultants (who may be expatriates) to help in training, empower the technicians, and the boundary spanners, through playing the part of responsive roles.  In that vein, the Nigerian health care bureaucrats must be responsive to the needs of the HIV carrying population, their families’ and communities’ fears and concerns.

(2) In order to be effective, healthcare managers should be given discretionary responsibilities to be able to alter the organization’s relationship with its environment if it will help to reduce the threat and incidence of HIV/AIDS.  Working to achieve success with HIV clients in Nigeria may be very hard task to accomplish because of cultural taboos and misconceptions about HIV.  Many Nigerians have misconceptions about how HIV spread while others may not contemplate discussing how HIV/AIDS is contracted because of conservatism and traditional restrictions.  People may not understand the extent of the pandemic but believe that they do.  In other cases, HIV infected individuals would prefer to deal with religious and traditional believers, instead of dealing with healthcare personnel where HIV infection methods could be discussed.  In extreme cases the traditional healers may convince HIV patients that they have been healed mostly by divine intervention.

(3) Healthcare personnel should assume the confident air that they can make a difference in solving the problems of the patients.  Managers should tell success stories of patients who have lived a long and healthy life with HIV with proper care and medical therapy.  Training sessions involving highly respected community leaders encouraging communities to be involved would grant credibility and acceptance of lessons.  Healthcare managers should bring people who are HIV-positive but of high moral standing to become spokespersons for an anti-HIV drive.  Nigeria has recently started using a young girl who contracted the HIV through rape as a symbol attesting to the Nigerian communities that not all that have contracted HIV did so through unacceptable behavior.

In general, the managers must be able to carry out policies that will encourage workers to perform optimally.  Workers that exhibit outstanding performance at work ought to be commended and praised without alienating workers who have performed services that were not easily isolated and evaluated. Workers should be paid their salaries regularly and in time and salaries should be raised to a level that will exemplify worth of the efforts that are expected of the workers.

Recommended Changes

Because the HIV/AIDS pandemic is a very new challenge to the health service industries in Nigeria, all the operating administrative frames need to be reviewed, assessed, and reframed.   Reframing the organization that provides HIV/AIDS preventive and treatment services in Nigeria should consider using the following four frames: (1) Strategic Planning Frame, (2) Human Resource Frame, (3) Political Frame, and (4) Symbolic Frame.  All or parts of the aforementioned frames will be expected to be combined in the bid to produce an administrative system that best suits the Nigeria HIV/AIDS environment and will be implemented as follow:

Structural Frames: In trying to develop a responsive organization to serve the interest of HIV/AIDS patients, the health care department should plan strategically to obtain the desired goal.  There should be a planning that would create the strategies for setting objectives, establishing and coordinating resource to achieve the goal of reducing the spread of HIV.  One of the strategies should be the reorganization of the department through the re-alignment of roles and responsibilities of the different individuals and parts of the department to fit the task and the new environment.  Motivating the staff would be very important if the department is going to provide a quality service to its clients.

Human Resource Frame: Participation in open decision-making should be encouraged.  Since the system had been a strictly top-to-bottom power flow system, encouraging people to make suggestions and give their opinion during the planning stages could become a motivation factor for them to participate as parts of the enterprise.  The open process can be used in conflict resolution through the principles of developing relationships and having individuals confront the conflict.  There should be liberalization of communication between the different hierarchies in the health care department.  Information should be exchanged and individual feelings shared through formal and informal meetings (Bolman and Deal, 2003).

Political Frames: The current political frame in the Nigerian Health Care Department responsible for treatment and prevention of HIV/AIDS concentrate power at the top of the hierarchy.  This appears to stifle the opportunity to use discretion in the discharge of service by the lower management cadre.  Then it should be necessary that power is redistributed to encourage more discretion on the part of lower cadre managers and street level bureaucrats who have day to day contacts with the HIV/AIDS clients.

Symbolic Frame:  As a symbol of change from the corrupt and redundant ways of the past, the government (Health Care Department) should reassign or terminate the services of certain departments’ heads whose department had been notorious in corrupt practices.  However, the organization does tend to maintain the image of accountability and responsiveness (Bolman and Deal, 2003, p.306) to the needs of the Nigerian people.  At the same time workers who have kept faith with the HIV-positive clients should be recognized and openly praised.  Through meeting and gatherings staged to recognize exceptional workers, the head may introduce the new values and culture of the department.  The recent Nigerian government’s effort of employing the services of a teenager (Jegede-Ekpe, 2003) who was known to be of good moral character but was diagnosed with HIV raises consciousness and awareness of the dreaded disease.  It puts a face of an innocent girl on a disease which many Nigerians have felt could only be contracted by lewd behavior.  To up-grade the symbolism of Jegede-Ekpe’s infection, she was recently honored by Reebok in New York as an extra-ordinary woman from Nigeria (African Sun Times 2003).

Further, administrators should be trained on how to discuss HIV-related issues with the conservative but trusted community leaders.  It would be easier to educate the residents of the communities about the AIDS virus, how it is contracted, and how to limit its spread.  The public must be encouraged to observe and believe that Nigeria’s healthcare department has changed from its apathetic state to being responsive to the needs of the community.  Unless the public sees the initiative as being responsive to their needs, it will fail. (Berman 1996).  Restructuring the healthcare department would be very vital to the success of the anti-HIV program and its management.  The existing, strictly top-to-bottom flow of administrative power may not lend itself to a successful anti-HIV program because there are several different communities, influenced by different special interest groups, and different religious and traditional affiliates.  Each of these groups also has their own cultures and expectations. In order to better serve all of them successfully, the low level bureaucrats should be empowered with discretionary powers and liberal communication routes to network with each other and with their supervisors.

Conclusion

Reframing and restructuring of the entire Nigerian government bureaucracy is necessary for efficiently carrying out government functions.  The need for effectiveness of the responsible agencies to HIV/AIDS management, immediate training, and re-culturalization of the employees is viewed as utmost importance if Nigeria is to actively confront the threat of this pandemic disease.  Such re-culturization should confront corruption, apathy, and redundancy that are endemic in the system.  It could be achieved if it is coupled with major re-organizational processes that will improve the communication between one worker and another worker and a worker, and his or her supervisor.  Training sessions, workshops, and meetings should be used to motivate, build confidence, instill the sense of belonging, empower workers, and transform them into being receptive to sharing information about HIV/AIDS and how it is contracted.

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*Prof. Dennis O. Balogu is Professor of Agriculture and International Affairs Officer at the University of Arkansas at Pine Bluff, AR 71601, U.S.A.

Literature Cited

Berman. 1996. Local Government and Community Bases Strategies, evidence from a national survey of a social  problems       Am. Review of Paul. Adm: 26: 71-91 

Bolman and Deals. 2003. In:   Reframing organizations: Artistry, Choice and Leadership. 3^rd Edition. Jossey- Bass- A. Wiley Imprint. www.josseybass.com 

Jegede-Ekpe, Y. 2003. Nigerian AIDS Activist, Honored by Reebok. African Sun Times. Vol. 14 No. 25, May 7-13, 2003.

Pfeffer, J. and G. Salaneik. 1978. Greatest Hits from Organizations: The External Control of Organizations.  In:   Reframing organizations: Artistry, Choice and Leadership. 3^rd Edition. Jossey- Bass- A. Wiley Imprint. 2003, p. 235.

Wilson J.Q. 1989. Bureaucracy: What government Agencies do and why the do it?  Basic Books:  A member of the Perseus Books Group.  http://www/basicbooks.com